Offline Registration form   (Bank transfer)	
 　　   2nd World Congress of Clinical Safety
- Risk in Clinical Care-
By International Association of Risk Management in Medicine (IARMM)
   	   　　　　　　　　　     　  　12th (Thus) - 13th (Fri) September, 2013
Heidelberg University, Heidelberg, Germany

Registration deadline:  31th August, 2013
After you fill this registration form, fax it to the following registration office (+81-3-3817-6770).

Male □　　　　 　　Female □ 

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▲ First name                                        ▲ Middle name    
      
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▲ Last name                                        ▲ Telephone number
                                                 
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▲ Title                                          　 ▲ Fax number
                                                 
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▲ Institution                                      　▲ Email address

▲	Postal address　   

A. Registration fee                                                     	
This registration is not valid before our confirmation of your payment.
Please mark ㇾ at your choice.  
	IARMM non-member 
Price 	IARMM member and Student Price	
Delegate Fee Thursday 12th & Friday 13th September 2013
 (The price is tax free.)	(     )  euro 300 	(     )  euro 220	
Delegate Fee Thursday 12th September 2013
 (The price is tax free.)	(     )  euro 150	(     )  euro 110	
Delegate Fee Friday 13th September 2013
 (The price is tax free.)	(     )  euro 150	(     )  euro 110	
Dinner Ticket
(not included in any package, *price includes VAT)	(     )   euro 65*	(     )   euro 65*	

* If your trust or organisation are not paying for your dinner ticket you should register as a delegate to receive your invoice for the delegate registration only and you can then register separately for your gala dinner tickets to receive a separate invoice.
 (Term condition)  On a case of cancellation, registration fee is not refunded.
When a delegate replaces with another person, email the request to the following office.

B. Hotel accommodation	
  Followings are our recommendation for your search.
   http://www.soas.ac.uk/visitors/location/hotels/
http://www.soas.ac.uk/visitors/location/hostels/

Please note that URMPM in no way indorse these hotels or take responsibility for your booking with your chosen hotel. Your booking is a contract between yourself and your chosen hotel.

C. registration payment way	
　　  　　　　　　
In a case of credit card payment, use our online payment system (PayPal Ltd) in the Congress homepage.
http://www.urmpm.org/UWC2012/
  .           Only VISA or MASTERCARD are available.
Your signature and password are not necessary.
Don’t need to use this registration form.

In a case of bank transfer, send the following bank account.
Bank name: Bank of Tokyo-Mitsubishi UFJ
Branch name: Hongo Branch
Branch number: 351
Account name: IARMM
Account number: ０１１１７１９
Sift code: BOTKJPJT

(Note)  For check use, you have to get an international check (Demand Draft) in your bank.  Thus, instead of check payment, you should use the following bank transfer. We don’t accept any check. 

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In a case of bank transfer payment, please fax this form to the following office till the registration deadline.
And, fax a copy of your receipt, too.

URMPM World Congress 2012 in London
Administration Office
c/o World Health Risk Management Center
　　Union of Risk Management for Preventive Medicine (URMPM)
(Tel / Fax) 　+81-3--3817-6770 
(Email)  manager@urmpm.com
4-7-12-102 Hong, Bunkyoku, Tokyo,113-0033, JPN